Tiils Abstract Of tbe Application is to be filled up at the Ollice only,
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1 Dues, . . .
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Number \
Date fret payment,
Date regular
Date of issue,
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Amount, $ — * - -~-
Approved by
APPLICATION FOR A MEMBERSHIP IN
Weight ?
Name of Member,
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Mutual Fin# SULite
Part i. Bryant Building, 55 Liberty Street, New York.
. 1. Name, at
OcCUpatlOn , If a Clerk, Salesman, or Merchant, alaie article* dealt In. If a Meobanlo or Laborer, state what kind
( AL1. APPLICATIONS MVST BE WRITTEN IN INK.)
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'■ full length, of the Applicant for Cgrtifcate, . . .
County,
Residence, 4 wit yfdtx
. . . . - . State, 4
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2. Name of the Person for whose benefit the Certific
Residence, . .
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P, 0 # Address,
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Shall Notices of Dues and Assessments be addressed )
to the applicant at P. 0, Address as stated above ? J
The " P. O. Addrci.," If ool ■ pool all/ Rlreu, will be assumed iw be the fame aa " Residence."
. Relationship to the Applicant,. . *d/ C-zv X . .
3. Sum applied for, 8
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J The dues are limited to $2.00 annually on each $i,ooo, payable in advance.
фе(Нса!
Ex
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Place and Date of Birth of the Applicant?
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PLACE.
COUNTY.
STATE.
DAY.
MONTH.
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0. Applicant’s age at nearest birthday?
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Height? £ k,S~ //\ c^\. Whether married ?
7. a. Are the habits of the Applicant at the present time, and have they always been, sober
and temperate?
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Is the applicant now and usually in good health?
C. Is the applicant now, or has he ever been, engaged in Xny way in the retailing of
alcoholic liquors.
8. Is the applicant subject to or predisposed to Dyspepsia, Dysentery, Diarrhoea, or any
other disease or bodily infirmity?
9. Has the applicant ever had any local disease, personal injury, serious illness, or other
infirmity ? If yes, state nature, date, duration, and severity of attack.
10. State the family history of the applicant wltose life is proposed to be insured in answer to the following particulars:
N. B.-Ib giving -
С»ш
of Death," ovoid oil ledeflnl te
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such
оа
•• Fever."
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General Dobllll/'- ••
КжровигеГ
etc. It tbe word •• Childbirth - bo ued,
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bow long after delivery the death occurred, ood whether It woa ooccm pooled by ooj disease of lha Cheat.
| Age, (if Living.)
Condition of HeaUh.1
Age at Death.
Cause of Death. *
FMbeJi _
Mother, f7fj
IX.
BROTHERS, •
SISTERS, - <
How many has the
person bad?
•y •
Uu* many
UvtogT
f,
Their Agea aod Butt of Health
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Bov many are
dead T
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At what age*
did tfcejdler
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Of what DUea.ee did they dloT
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1 2 Age and Cause of Death of Paternal Grand Father, ff 6 ^ L 7-
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•4 Grand Mother, /
Age and Cause of Death of Maternal Grand Father,
“ “ Grand Mother. ^
13. Has either of the parents or any brother or sister of the applicant died of, or been afflicted
with Consumption, Scrofula, Insanity, Gout, or any pulmonary complaint, or any
hereditary disease? (State particulars.)
14. Is the applicant now insured in this Association, or has he ever been ?
If so, state Numbers of Certificates and amount.
15. Has the applicant any other insurance on his life? If so, where, when taken, for what
amounts, and what kinds of policies?
16. Has any proposal to insure the life of the applicant ever been declined ? If so, by what
Company or Association ?
17.
Has any proposal or application to insure the life of the applicant ever been made to any
Company, Association, or Agent upon which a policy or certificate of membership has
not been received by you for the full amount and kind, and at rate applied for?
18. Has any physician given an unfavorable opinion upon the life of the applicant with refer¬
ence to Life Insurance or otherwise? if so, state pariiculars.
19. Do you understand and agree, that the use of alcoholic drinks to any excess, or habitual
use of opium or other narcotics, will forfeit your membership?
20. Have any material facts regarding your past health or present condition been. omitted ?
State facts fully.
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21. Name and residence of applicant’s usual Medical Attendant? On what occasions, and
for what diseases have you required his attendance and advice ?
22. Have you consulted any physician regarding your health within the past 5 years ? If so,
when, and for what disease?
23. Name and residence of two personal friends, to whom you refer?
A.
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It is hereby Warranted by the applicant, that the answer* and statements in this application, whether written by his own hand or not, arc full, complete, and true, and it is agreed that this warranty shall form the basis and shall be
a part of the contract between the undersigned and The Mutual Reserve Fund Like Association, and are offered to said Association, as a consideration of the Contract applied for, and subject to all die limitations and requirements of the
Constitution and
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of said Association, all of which are hereby made part ol the Certificate to be issued on this Application. And the applicant further agrees that if any of die statements, repreaciuauons, or answeis made herein arc
not true, full, and complete, or if he or his representatives shall omit or neglect to make any payment as required by the conditions of such Certificate, or by the Constitution and By-Laws of said Association, then the Certificate to be Lsucd
hereon shall be null and void, and all money paid thereon shall be forfeited to said Associadon. That, inasmuch as only the officers at the Home Office of the Association, in the City of New York, have authority to determine whether or not
a Certificate shall issue on any Application, and as they act on the written statement and representations referred to, no statements, representations or informadon made or giveu by or to the person soliciting or taking this Applicadon foi a
Certificate, or to any other peison, shall be binding on the Associadon, or in any manner affect its rights, unless such statements, representations, or informadon be reduced to wriung, and presented to the officers of the Association at the Home
Office, in this Application. That under no circumstances shall the Certificate hereby applied for be in force undl the actual payment to, and acceptance of, the first annual dues by the Associadon, and actual delivery ot the Certificate to the
applicant, with a receipt for the payment of the first annual dues, signed by the President, Secretary, or Treasurer of the Association, during the life dine of the applicant. And it is further agreed that the Associadon shall not be liable under
said contract if death shall be caused by the hands of jusdee, or in consequence of the violation of any law. .
The HUSBAND may sign for Ills WIFE, or t he FATHER for JiU CHILDREN.
Dated at — //hi d
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* Witness as to the Signatures. , - —
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^ _ _ Agent .
Form 1.
L^NOTE BEFORE SIGNING.
